text:
|Número de publicación
|Tipo de publicación
|Número de solicitud
|Fecha de publicación
|21 May 1996
|Fecha de presentación
|9 May 1994
|Fecha de prioridad
|13 Oct 1992
|También publicado como
|Número de publicación
|Prakash Keshaviah, James P. Ebben, Paul F. Emerson, David A. Luhring
|Cesionario original
|Baxter International Inc.
|Exportar cita
|BiBTeX, EndNote, RefMan
|Citas de patentes (20), Otras citas (8), Citada por (101), Clasificaciones (17), Eventos legales (5)
|Enlaces externos: USPTO, Cesión de USPTO, Espacenet
This is a continuation of application Ser. No. 07/959,922, filed Oct. 13, 1992, now abandoned.
The present invention relates generally to hemodialysis machines, and more particularly is directed to an improved system for on line real time monitoring of the effectiveness of the hemodialysis treatment.
The use of dialyzer cartridges with hemodialysis machines to remove blood-borne toxins and by-products of metabolism has been conventional for many years. Typically, such a cartridge contains essentially a pair of chambers separated by a semipermeable membrane. Blood is perfused through the first chamber and returned to the patient. The dialysate solution is simultaneously circulated in the opposite direction through the second chamber. A concentration gradient thereby is established which causes waste products carded in the blood to migrate through the semipermeable membrane and into the dialysate solution to form the dialysate effluent.
The principle of hemodialysis has been refined extensively. A number of semipermeable hollow fiber membranes are now utilized in dialyzer cartridges to greatly increase the total membrane surface area to facilitate diffusion across the membrane structure. The hollow fiber membranes include a variety of materials including, for example, cellulose acetate, cellulose triacetate, polyacrylonitrile, polysulfone, and regenerated cellulose, the latter being most commonly used.
One of the most basic considerations in treating a patient with hemodialysis revolves around treatment adequacy. For instance, how long should a given patient be dialyzed on a given day. A number of medically adverse effects may result from an inadvertent failure to sufficiently dialyze the patient. At the present time, the average dialysis patient has a life expectancy of only about five years. One reason these patients tend to have a short life expectancy is the deleterious effect of a chronic buildup of various toxins that either are not eliminated at all, i.e. do not pass through the hollow fibers, or are not sufficiently reduced to nontoxic levels. The identity of many of these supposed toxins is not known, although those species known to be eliminated in urine, such as urea, creatinine, phosphate, hydrogen ions, etc. are associated with serious medical consequences when permitted to accumulate in excess of normal levels.
A number of factors can have a substantial effect on treatment adequacy. For example, it is common practice in the field of hemodialysis to reuse the dialysis cartridges. There is technology available for cleaning, disinfecting, or sterilizing used dialysis cartridges, for example, as illustrated in U.S. Pat. No. 4,695,385. Eventually, however, an individual cartridge must be discarded because it loses its dialyzing competency. At the present time, the competency of dialyzers is difficult to assess and therefore often is not rigorously monitored, and a dialyzer cartridge is often not discarded until it visually appears unclean after recleaning, or when fiber bundle volumes or ultrafiltration rates are reduced below a predetermined threshold. It now is known that severe dialyzer dysfunction can occur even when appearance, fiber bundle volume and ultrafiltration rates are normal, as reported by Delmez et al., "Severe dialyzer dysfunction during reuse," Kidney International, 35:244 (1989). It is also known that dialyzer competency can not be accurately predicted by the age of the dialyzer cartridge or the number of uses.
Notwithstanding the condition of the dialyzer, one measure of adequacy of dialysis for the individual patient during a given treatment is calculated from the following equation:
V is an expression of the volume of distribution of urea which is approximately equal to total body fluid volume. V is derived for each individual patient from data such as height, weight and sex. K is the urea clearance of the particular dialyzer in use in milliliters (ml) of blood cleared of urea each minute. T is the treatment time. K is obtained from the typical product insert enclosed with a case of dialyzers and contains a graph of urea clearance versus blood flow rate obtained by random testing of a sample of dialyzers from a particular manufacturing lot. Upon incorporating these values into the above equation, the minimum treatment time can be calculated for a given KT/V value. Other parameters that may be varied to achieve adequate dialysis include blood flow rate, dialysis solution flow rate, dialyzer competency, and temperature.
It has been determined empirically that KT/V values of about 0.8 or greater are associated with low levels of morbidity. See Gotch, L. A., Sargent, J. A. Kidney International, 28:526-537, 1985. Even with the use of new dialyzers there is some risk that a unit selected from a particular lot will have a significantly lower K value than the value indicated in the product insert. The patient receiving treatment from such a dialyzer is therefore at risk of being under-dialyzed. The likelihood of under-dialysis increases upon reuse of the dialyzer cartridge because of the definite but unquantified loss of dialyzer competence with each successive use. Underdialysis also may occur because of incompetency of access to the patient's circulation. Because of incompetency of the patient's blood access, desired blood flow rates may not be achieved which also can result in underdialysis.
Other parameters than KT/V have also been determined to assess the adequacy of dialysis. Among these are the Urea Reduction Ratio (URR) and Solute Removal Index (SRI). URR is defined as 1-(CB)pre /CB)post. A good dialysis treatment will have a URR near one (1) while a poor dialysis treatment will have a URR near zero (0). Unfortunately URR does not take into account generation of urea during dialysis, ultrafiltration, or the two pool nature of removal. Consequently SRI has been proposed as a generalized version of URR which does account for these effects. SRI is defined as the amount of urea removed during a treatment as a fraction of the total body store. Like URR, a good dialysis treatment will have an SRI value near one (1) while a poor dialysis treatment will have an SRI near zero (0). Potentially SRI (unlike KT/V) can indicate the adequacy of a dialysis treatment irrespective of modality (i.e. peritoneal or hemodialysis) and intermittence. Neither URR or SRI however, have been validated as extensively as KT/V as measures of dialysis adequacy.
Although the KT/V, URR and SRI indices are indicative of urea removal and appear to correlate to therapy failure, that is not tantamount to saying that urea is a toxic metabolite. There is early literature to suggest that urea is not toxic, per se. However, urea is a major metabolite of protein catabolism and serves as a convenient marker to monitor treatment adequacy.
Urea has a molecular weight of 60 daltons while some of the other protein catabolites may be much larger. It has, therefore, become a subject of controversy whether the relationship between KT/V and morbidity established with the tighter cellulosic membranes is applicable to the more open membranes used for hemofiltration and high flux hemodialysis or to the natural peritoneal membrane.
There is a considerable body of literature on the urea kinetic model. Computer programs, programmable calculators and time-shared computer services have been determined to make urea kinetics more accessible to the dialysis clinician. It has recently been shown (Lindsay, et at, 1989) that KT/V values of less than 0.8 may be associated with a low dietary protein intake that is intractable to nutritional counseling. However, increasing the KT/V to 1.0 or higher, in conjunction with nutritional counseling, is effective in improving dietary protein intake. As low dietary protein intake may be associated with increased morbidity, monitoring of the KT/V and nPCR are useful adjuncts to other clinical assessments of the dialysis patient.
Traditional urea kinetics entails numerous measurements and is considered mathematically complex by dialysis clinicians. The various measurements required for accurate kinetic measurements are summarized in Table 1.
Pre dialysis BUN (C1)
Post dialysis BUN (C2)
Pre dialysis BUN for next dialysis (C3)
Dialyzer clearance (K)
Blood flow rate
Arterial BUN
Venous BUN
Dialysate flow rate (effluent) (QDo)
Access recirculation
Peripheral BUN
Residual renal function
Urine volume
Urine concentration
Dialysis duration (td)
Off dialysis duration (tod)
Ultrafiltration rate
Weight gain between dialyses
Each of these measurements is associated with finite error and the cumulative effect of these errors may lead to unrealistic urea kinetic parameters.
Prior art hemodialysis machines have not had the capability of on-line monitoring of the hemodialysis treatment. Further, the prior art techniques generally have required the taking of blood samples from the hemodialysis patient.
It thus would be desirable to provide a non-invasive on-line real time monitoring of the hemodialysis treatment while the patient is attached to the hemodialysis machine. The treatment when based on urea kinetics preferably would require measurements of effluent dialysate concentrations and flow but not of blood samples. The treatment would yield as outputs the KT/V, URR and SRI indices of therapy adequacy, the urea removal and the normalized protein catabolic rate (nPCR) which then could be utilized to assess dietary compliance and adequacy of treatment in real time.
The present invention is directed to an improved on-line real time hemodialysis monitoring method and system for hemodialysis machines. The hemodialysis monitoring system quantitates the rate and amount of urea removed during the hemodialysis treatment by measuring the urea concentration in the spent dialysate effluent as a function of time. The dialysate effluent line from the hemodialysis machine is sampled periodically to remove a small volume of the spent dialysate effluent when a sufficient fluid flow is sensed. The urea concentration-time profile is determined and analyzed to determined the urea removal, KT/V, URR and normalized protein catabolic rate (nPCR). The hemodialysis monitoring system and urea monitor configuration can be changed to allow equilibrium of blood in the dialysate effluent prior to the start of and at the end of a hemodialysis treatment. The hemodialysis monitoring system also can include a two pool analysis taking into account the different degree of urea depletion from the extracellular and intracellular spaces in the hemodialysis patient during treatment. This allows the calculation of the solute removal index (SRI).
These and other features and advantages of the invention will be more readily apparent upon reading the following description of a preferred exemplified embodiment of the invention and upon reference to the accompanying drawings wherein:
FIG. 1 is a block diagram of one embodiment of the hemodialysis monitoring system of the present invention;
FIG. 2 is a schematic diagram of one embodiment of a portion of the hemodialysis monitoring system of FIG. 1;
FIG. 3 is a partial block and partial schematic diagram of the fluid functions of the hemodialysis monitoring system;
FIG. 4 is a urea concentration time profile of a typical patient illustrating a two pool analysis of the patient;
FIG. 5 is a functional block diagram illustrating the equilibration of the hemodialysis monitoring system;
FIG. 6 is a flow chart of the preferred embodiments of the present invention.
While the invention will be described and disclosed in connection with certain preferred embodiments and procedures, it is not intended to limit the invention to those specific embodiments. Rather it is intended to cover all such alternative embodiments and modifications as fall within the spirit and scope of the invention.
Referring to FIG. 1, one embodiment of a hemodialysis monitoring system of the present invention is designated generally by the reference numeral 10. The monitor 10 includes an input module 12, which can in the preferred embodiment be a urea sensor or an appropriate sensor for sensing a different molecule or constituent to be cleared. The module 12 samples a volume of the dialysate effluent intermittently, as desired. The module 12 couples the dialysate sample volume to a sensor 14 via a line 16. The sensor 14 generates a signal which is proportional to the monitored constituent concentration and couples that signal to a constituent signal analyzer 18 via a line 20.
The module 12 can be any type of sampling device which is coupled, preferably permanently, to the dialysate effluent line (not illustrated). A preferred input module 12 is disclosed and described in copending application docket number DI-4354 (65889-108), entitled FLUID SAMPLING MODULE, filed concurrently herewith, which is incorporated herein by reference. The urea sensor 14 can be a sensor, such as described in U.S. Pat. No. 4,686,479, entitled APPARATUS AND CONTROL KIT FOR ANALYZING BLOOD SAMPLE VALUES INCLUDING HEMATOCRIT, which also is incorporated herein by reference. The liquid sample is contacted with a urea sensor that includes a urease layer associated with an electrode adapted to generate output in response to ammonium ions. The urease layer converts a portion of the urea in the sample to ammonium ions, and the ions contact the electrode to generate output related to the urea concentration in the sample.
The sensor 14 is described herein for example purposes, as a urea sensor. There are other approaches to urea sensing and any urea sensor that can measure urea concentration in the effluent dialysate line can be utilized for this purpose. The invention, therefore, is not specific to a particular type of urea sensor. Urea, however, is just one of a number of identifiable constituents generally related to uremia in a patient's blood, which can be utilized as a marker or measure of the effectiveness of the hemodialysis treatment, i.e. the removal of toxins. Such other constituents are, for example, creatinine, uric acid, phosphate, calcium, sodium, potassium, glucose, beta 2 microglobulin, among others. Other types of sensors also can be utilized in the hemodialysis monitoring system of the present invention, which sense the required fluid constituent(s) directly or indirectly.
There are also other approaches to the flow configuration of the urea sensor. The most direct configuration is location of the urea sensor in the effluent dialysate stream. Another direct configuration is taking the sample volume from the fluid stream and flowing the sample volume past the sensor. Other configurations could include:
1. Locating the sensor in the fresh inflow dialysate stream with effluent dialysate being pumped in, upstream of the sensor, in a flow injection mode.
2. Pumping inflow and outflow streams in the desired proportions for dilution past the urea sensor.
3. A flow injection scheme where a carrier buffer stream is pumped past the urea sensor with injection of effluent dialysate into this buffer stream.
One urea input/sensor module embodiment of the urea input module 12 and the urea sensor 14 of the hemodialysis monitoring system 10 of the present invention is designated generally by the reference numeral 30 in FIG. 2. The module 30 includes a sample port 32, which preferably forms a part of a discharge or dialysate effluent line 34. The module 30 taps into the dialysate effluent line 34 via a junction 36 coupled to a sampling line 38.
The module 30 samples the dialysate effluent by activating a self occluding peristaltic or roller pump 40. The line 38 is coupled to a junction 42 and to a normally closed valve 44. The junction 42 also is coupled to a line 46, which includes a storage coil 48. The storage coil 48 is first filled with the dialysate effluent, with the excess dialysate effluent continuing through the line 46 to a separator 50. The separator 50 includes an air gap, which prevents a backup of the dialysate effluent and also prevents an electrical short through the line 52.
Once the storage coil 48 is filled, the pump 40 is stopped, which closes the line 38 from the junction 36. The valve 44 then is opened allowing the sample dialysate to flow through the valve into a line 54 and then to and past the urea sensor 14. The sample dialysate is caused to flow by a sample pump 56, which is coupled between the urea sensor 14 and the discharge separator 50 by a line 58.
For each measurement, sample dialysate preferably is input to the urea sensor 14 and flushed through the separator 50 several times to ensure a good sample value. At the same time the sample dialysate is pumped through the urea sensor 14, a reference fluid from a source 60 also is pumped into the urea sensor 14 via a line 62 and a second pump 64. The second pump 64 preferably can be a second roller head on the sample pump 56, but could also be a second pump coupled to operate at the same time as the sample pump 56.
As shown in more detail in U.S. Pat. No. 4,686,479, the urea sensor 14 includes an air detector 66 to determine if the sample dialysate is present in the urea sensor 14. The sensor 14 employs an electrode 68 with a membrane (not illustrated) which is specific to ammonium. The electrode 68 senses dialysate urea nitrogen (DUN) which is compared to a reference electrode 70. The signal generated by the sensor 14 then is coupled to the signal analyzer 18, as will be described in more detail hereinafter.
At the beginning of the hemodialysis treatment with a patient and periodically as desired, both a low reference standard and a high reference standard are run on the module 30 to calibrate the module 30. To calibrate the module 30 with the low standard, the valve 44 remains closed and a valve 72 is opened to allow the second pump 64 to draw in the low standard fluid from a source 74 via a line 76. The urea sensor 14 measures the low standard, which is compared to an expected range of values to ensure that the urea sensor 14 is calibrated correctly. The low standard also can be utilized to test the integrity of the system during treatment.
A similar operation is performed with a high reference standard. To run a high standard test, all the valves are closed, except for a high standard valve 78. The open valve 78 allows the second pump 64 to draw a high standard fluid from a source 80 via a line 82. The high standard fluid is measured in the urea sensor 14 and compared to an expected range of values to ensure that the urea sensor also is operating correctly at the high standard range.
At the end of the low standard cycle testing, the module 30 closes the valves 44, 72 and 78 and opens an air valve 84 for a period of time, which allows the sample pump 64 to draw air into a line 86 through the valve 84, the urea sensor 14 and out the discharge line 52. This air segment between each fluid segment helps ensure that the urea sensor 14 and the lines 54 and 58 are clean and empty of any substantial amount of residual fluid.
Referring now to FIG. 3, a schematic embodiment of the operation of the hemodialysis monitoring system 10 of the present invention is designated generally by the reference character 90. The system 90 is depicted diagrammatically as including an intracellular space (ICW) 92 and an extracellular space (ECW) 94, which spaces are representative of the body pools in a hemodialysis patient. The hemodialysis kinetic parameters in the system 90 are calculated from the spent dialysate of a patient undergoing a typical dialysis treatment. The urea is generated in the liver, which is illustrated as being a portion of the ECW 94.
Some of the urea may be removed by the patient's kidneys, if there is a residual renal function, as indicated by an arrow 96. The majority of the urea, however, is removed by the hemodialysis treatment after first contacting the blood 98 in the ECW 94, as indicated by an arrow 100. Urea also enters the ECW 94 from the ICW 92, as indicated by an arrow 102.
The blood is removed during the hemodialysis treatment by flowing through a line 104 into a dialysis cartridge 106. The dialysis cartridge 106 diagrammatically includes a dialyzer membrane 108 across which urea diffuses into the dialysate. A sample volume of the dialysis effluent is removed through the line 38 and then is sensed by the urea sensor 14, as above described. The blood returns to the patient via a line 110.
In a steady state condition, the total amount of urea removed during the hemodialysis treatment and sensed by the urea sensor 14 is equal to the rate of generation of urea in the patient's body in ECW 94. This allows the calculation of the normalized protein catabolic rate (nPCR) or the number of grams of urea generated per kilogram of body mass in a twenty-four hour period. Further, by knowing the concentration-time profile of urea, inferences can be made about the clearance of the dialyzer cartridge 106 and the clearance-time/body water index (KT/V) which is a measure of dialysis adequacy then can be calculated.
FIG. 4 illustrates a urea concentration-time profile of a typical patient as detected by the urea sensor 14. Applicants have discovered that the urea concentration-time profile can be closely matched to an early fit exponential curve 112 and to a late fit exponential curve 114. The two curves 112 and 114 are exponential fits of the urea concentration data pre and post thirty (30) minutes into the hemodialysis treatment. An empirically determined "inflection" point 116 is indicative of the difference in the fits 112 and 114, which is a gradual shift caused by the two-pool nature of the urea removal from the patient's ICW 92 and ECW 94.
Initially in the hemodialysis treatment, the system 90 removes urea quite rapidly from the patient's blood and from the ECW 94 with which the blood 98 is in intimate contact. Thus, the initial fit 112, before the point 116 is a fairly steep slope. After a period of time, approximately thirty (30) minutes, enough urea is removed from the ECW 94 to create a urea gradient between the ICW 92 and the ECW 94.
At the point 116, the rate of urea removal from the ECW 94 decreases and the rate of urea removal from the cells in the ICW 92 increases. The latter is a result of a growing concentration differential between the ECW 94 and the ICW 92. The removal of urea from the patient's body is dependent upon the intercompartmental mass transfer area coefficient (iMTAC) (which controls mass transfer between the ICW 92 and ECW 94) and the dialyzer mass transfer area coefficient (dMTAC)(which controls the mass transfer between the ECW 94 and the dialysate flow). The iMTAC is typically smaller than the dMTAC which causes the concentration differential between the ECW 94 and ICW 92. Consequently the fit 114 after the point 116 has a more flat slope, than the slope of the early fit 112. It thus is clear that a single pool analysis is much less accurate than the two pool behavior as determined by the present invention.
The calculation of KT/V, URR and SRI employing the two pool analysis in accordance with either of the systems 10 or 30 is as follows. In one preferred embodiment, prior to initiating the hemodialysis treatment, the hemodialysis monitoring system 10 or 30 of the present invention, for example purposes, is equilibrated with the patient's blood as illustrated in FIG. 5. The blood is pumped to the dialysis cartridge 106 via the line 104, such as by a roller pump 118. The dialysis cartridge 106 is connected to and forms a portion of a conventional dialysis machine 120.
To obtain the equilibrated urea sample analysis, after initial filling of the dialyzer with dialysate, the dialysate flow is shunted past the dialysis cartridge 106 or stopped, while the blood is pumped through the dialysis cartridge 106. No dialysate flow is allowed between the dialysis cartridge 106 and the dialysis machine 120, however ultrafiltration does exist even with the dialysate flow in bypass. After an elapsed time period, such as five (5) minutes, during which the urea concentrations of the blood and the dialysate are allowed to equilibrate across the membrane, an equilibration sample is obtained and sensed by the urea sensor 14. The equilibration sample provides the urea concentration in the patient's blood before the dialysis treatment. The equilibrated concentration is utilized in conjunction with the dialyzer typical profiles, dialysate clearance (K) and total body water (V) to calculate KT/V, URR, nPCR, and the solute removal index (SRI).
Utilizing a first preferred embodiment of the hemodialysis monitoring system 10, without obtaining an equilibrated sample, the following steps are performed, as illustrated in FIG. 6:
1. Two exponential regressions of the concentration/time profile are performed, with the first regression fit coveting the segment from zero to thirty (0-30) minutes, and the second regression fit coveting the segment from thirty (30) minutes to the current time as indicated by block 122.
2. The initial (CD1), thirty (30) minute (CD30), current minute (CDi), and final (CD2) dialysate urea concentrations are projected from these regressions and the log mean dialysate concentration is calculated for each segment as indicated by block 124.
3. Urea removal for each segment then is calculated as the product of log mean dialysate concentrations, dialysate outflow (QDo) and segment time. These products are summed to obtain the projected urea removal (R) for the dialysis treatment as indicated by block 126.
4. Because of the typical unequal spacing of dialysis treatments over a seven (7) day period, urea removal for a given treatment is dependent upon the day of the week. A factor (F) was derived from a variable volume urea kinetic model utilizing a range of clearances (K), urea distribution volumes (V), urea generation rates (G), ultrafiltration rates (Qu), and treatment times (T). The projected weekly removal (Rwk) is calculated using F and R.
5. G (in mg/minute) then is calculated from Rwk.
6. Qu is calculated from total ultrafiltration and treatment time.
7. A "first guess" (estimate) for KT/V is calculated utilizing the formula (KT/V)fg =LN(CD1 /CD2), with CD1 and CD2 projected from the exponential regressions of the time/concentration profile as indicated by block 128.
8. K and Qu /K are calculated from (KT/V)fg and an estimate of V (as percentage of body weight; 51% for males, 43% for females).
9. Qu T/V and hence a new KT/V are calculated as indicated by block 130 utilizing the formula: ##EQU1## 10. A new K is calculated from the KT/V obtained in step 9. 11. Iteration of steps 9-10 is continued until convergence is obtained which results in a final KT/V as indicated by block 132.
12. The normalized protein catabolic rate (nPCR) then is calculated utilizing G and V as indicated by block 134.
13. In lieu of KT/V, URR can also be reported as 1-CD1 /CD2.
Utilizing a second preferred embodiment of the hemodialysis monitoring system 10, after first obtaining an equilibrated sample, the following steps are performed, as also illustrated in FIG. 6:
The dialysate sample has been equilibrated with blood before the dialysis treatment (Cbequil) (as described elsewhere) as indicated by block 136:
1. Steps 1-6 are performed as above.
7. Clearance (K) is calculated directly from Cbequil, QDo and CD1 as indicated by block 138.
8. KT/V is calculated utilizing the formula in step 9 above as indicated by block 140.
9. Kinetic volume of urea distribution (V2) is calculated from KT/V (step 3) as indicated by a block 126' and K (step 2) as indicated by block 138.
10. Solute Reduction Index (SRI) represents the fraction of solute (urea) that has been removed from the total body stores by hemodialysis and is calculated as indicated by block 140 from:
SRI=[R-G*T(dialysis)]/(V1 *Cbequil)
where V1 =V2 +ultrafiltration.
11. The normalized protein catabolic rate (nPCR) then is calculated utilizing G and V as before as indicated by block 134'.
12. In lieu of KT/V, URR can also be reported as 1-CD1 /CD2.
The first embodiment can be utilized where the system 10 is not an integral portion of a hemodialysis machine, since the equilibrated sample then must be obtained by an operator in a manual mode of operation. The second embodiment preferably can be utilized when the system 10 is integrated with or is able to automatically control the hemodialysis machine to automatically obtain the equilibrated sample without operator intervention.
As further embodiments:
1. The concentration/time profile also could be fit with a single exponential regression to project CD1, CD2, and R.
2. The concentration/time profile could be fit with a non-linear regression (e.g. the sum of two exponentials). The exponents resulting from these regressions then would be utilized to calculate K, G, and V utilizing standard two-pool urea kinetics determined for blood urea concentration/time profiles.
3. Also, a percent urea reduction method utilized for blood urea concentrations (e.g. a formula of the type: KT/V=-LN[Cpost/Cpre- 008*Time--Ultrafiltration/Weight]) could be utilized to calculate KT/V utilizing dialysate urea concentrations.
In the further embodiments, number 1 and 3 result in a KT/V that represents single-pool urea kinetics, while the preferred embodiments, previously described and the further embodiment number 2, result in a KT/V that represents two-pool urea kinetics.
The hemodialysis monitoring system 10 can draw a sample volume at any predetermined time period. It empirically has been determined that a time period on the order of every ten (10) minutes is sufficient for the hemodialysis treatment, since the urea concentration values change at a relatively slow rate. The rate change is sufficiently slow, such that continuous sampling is not required and intermittent sampling is sufficiently accurate to represent real time. Thus, sampling the dialysis effluent every five (5) to ten (10) minute period provides a real time urea concentration profile. A convenient sample volume, utilizing the urea sensor 14 is on the order of two (2) milliliters (ml) of dialysate effluent. The hemodialysis monitoring system 10 can also provide an equilibrated urea concentration value at the end of the hemodialysis treatment.
Because of the technique of the hemodialysis monitoring system 10 of the present invention, after about sixty (60) to ninety (90) minutes of a three (3) to four (4) hour hemodialysis treatment, the final urea concentration value can be projected. This mid-treatment projection then can be utilized to trouble shoot the hemodialysis treatment, if the final projected KT/V result is too low.
In a typical patient, when the hemodialysis treatment is initialized, the patient's blood will contain on the order of seventy (70) milligrams (mg) of urea in one hundred (100) ml of blood. After four (4) hours of the hemodialysis treatment, the patient's blood will contain on the order of thirty (30) mg of urea in one hundred (100) ml of blood. On the dialysate side of the dialysate cartridge 106, the dialysate after initiating treatment initially will contain on the order of twenty-five (25) mg of urea in one hundred (100) ml of dialysate. After the four (4) hours of the hemodialysis treatment, the dialysate will contain on the order of five (5) to seven (7) mg of urea in one hundred (100) ml of dialysate, since the clearance decreases during the hemodialysis treatment.
The urea change is exponential, such that about one half of the urea is removed in about one third of the total hemodialysis treatment time period. Since the urea change is exponential, it is convenient to sample more frequently in the initial part of the hemodialysis treatment time period. For example during a four (4) hour hemodialysis treatment, the hemodialysis monitoring system 10 can be set to sample every five (5) minutes in the first hour and then every ten (10) minutes during the rest of the hemodialysis treatment.
Applicants empirically have determined that the two pool analysis of the hemodialysis monitoring system 10, as described with respect to FIG. 4, is on the order of twelve (12) to eighteen (18) percent more accurate, than the conventional one pool analyses. The hemodialysis monitoring system 10 also is set to monitor the dialysis effluent, only when the hemodialysis machine 120 is operating. Some prior art systems utilize a total clock period, without regard to dialysis shut down periods due to system alarms.
Further, as is described in more detail in the above cross-referenced application, for a Fluid Sampling Module, the hemodialysis monitoring system 10 is prevented from sampling the dialysate effluent during a period of no or very low dialysate effluent flow. Sampling during a period of no or unstable flow, also can introduce errors into the analysis treatment. Urea is a convenient marker to utilize in the hemodialysis treatment, since it is related to other uremic toxin levels, but other well known markers also can be utilized in the hemodialysis treatment of the present invention as previously described.
The prior art hemodialysis monitoring treatment typically draws a blood sample from the patient (an invasive treatment), typically on the order of once a month. The urea concentration value then is utilized as the initial hemodialysis treatment value. The final or post hemodialysis treatment value is obtained from a blood sample taken after the end of the hemodialysis treatment. The urea concentration ratio from these two blood samples then is utilized to determine the efficiency of the hemodialysis treatment, which provides a KT/V value which is not as accurate as that obtained utilizing the present invention.
The prior art analysis is further inaccurate, because although the urea concentration in the ICW 92 attempts to equalize with that in the ECW 94, there is a considerable time lag. The urea is removed rapidly from the blood, resulting in a significant differential between the urea concentration in the ICW 92 and in the ECW 94 at the end of the hemodialysis treatment. At the end of a typical hemodialysis treatment, urea concentrations can be about forty (40) mg/dl in the ICW 92 and about thirty (30) mg/dl in the ECW 94. Thus, since the ICW 92 has a total nominal volume greater than the ECW 94 total nominal volume, the final ECW 94 urea concentration value of about thirty (30) mg/dl can be very inaccurate. The single or one pool analysis does not take into account the difference between the final urea concentration in the ICW 92 and the ECW 94. Since the one pool analysis generally is based upon the urea concentration in the ECW 94, if an equalization or rebound period on the order of thirty (30) to sixty (60) minutes is not accounted for, the analysis will overestimate the true KT/V. Continued diffusion from the ICW 92 into the ECW 94 causes the concentration of the ECW 94 to rebound or increase with time.
The hemodialysis monitoring system 10 is described as a separate unit, which is attached to the lines of the dialysis cartridge 106, which is pan of the dialysis machine 120. The hemodialysis monitoring system 10 also can be retrofit to the dialysis machine 120 or can be fully integrated into the dialysis machine 120 without departing from the spirit or scope of the present invention.
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text:
Bhopal media workshop dwells on decentralised planning
Oct 09, 2015 03:45 PM
Vikas ki behti dhara mein jan-bhagidari jaroori hai (People will have to participate in the development process), says Babulal Jain, Vice-Chairman, State Planning Commission.
[South Asia] [Media] [Decentralisation]
Indian NGO builds young advocates for gender equality
Oct 07, 2015 06:21 PM Through the National School Essay Contest, Nanhi Chhaan, a nonprofit has tried to educate the young citizens of the country on the anomalies of Indian society.
HSI-India slams killing of man accused of cow slaughter
Oct 03, 2015 07:40 PM As Indians celebrate Gandhi's birthday, HSI-India stresses that ahimsa applies to people and animals alike.
Rural distress fuelling up internal migration, say experts
Sep 23, 2015 12:03 PM
According to a social activist, the present rural distress is worse than 1950s with most of the affected people being small farmers.
[Rural communities] [Children] [South Asia] [Rural India] [Migration]
Innovative teachers of Delhi felicitated
Sep 18, 2015 11:56 AM STIR Education holds Govt Selection Day in association with Municipal Corporation of Delhi (MCD) & Department of Education (DoE) to felicitate most innovative teachers of Delhi.
Focus on neglected tropical diseases: WHO
Sep 13, 2015 10:32 PM The WHO South-East Asia Region reports around 10 000 cases of kala-azar every year.
India's breastfeeding policies need improvement: report
Sep 10, 2015 04:05 PM The South Asian counties managed to advance much further because the policy makers prioritized optimum breastfeeding and infant and child feeding, something India has not been able to do so far.
Prioritise preparedness for health emergencies: WHO
Sep 09, 2015 05:34 PM Over the years, WHO South-East Asia Region has witnessed a series of major public health emergencies.
Tapping CSR for strategic farmer-business linkages in India
Sep 07, 2015 02:11 PM Experts have urged for tapping CSR funds for creating farmer oriented market linkages to make farming a profitable vocation.
The Chalk Walk-2015: A teachers' movement
Sep 07, 2015 12:05 PM By participating in the Chalk Walk -12000 teachers in the movement took an oath to improve learning outcomes of children.
UN Hosts 12th International Human Rights Summit
Sep 04, 2015 11:43 AM With limitless energy, optimism and promise, the youths inspired UN staff, NGO representatives and other dignitaries attending the event.
IFRC appeals to support flood-hit people in Bangladesh
Sep 02, 2015 07:00 AM The floods, which began at the end of June, inundated hundreds of villages and left over 200,000 people stranded across the districts of Cox's Bazar, Chittagong and Bandarban.
Environment sustainability crucial for Smart Cities in India
Sep 02, 2015 11:48 AM
With the Indian government rooting for 'Smart Cities' there is an urgent need to ensure environmental sustainability of these projects.
[India] [Housing] [South Asia] [Enviornment]
India free of maternal, neonatal tetanus, says WHO
Aug 31, 2015 06:55 PM
The UN health agency has congratulated India on the eradication of the killer disease.
[South Asia] [India infant mortality] [Maternal mortality rate] [WHO] [Health MDGs]
Panchayat to run water treatment plant in Bihar village
Aug 31, 2015 05:10 PM
The community owned water treatment plant will provide clean drinking water to people at the nominal rates.
[South Asia] [Bihar] [Water and Sanitation] [SWASTH Bihar] [Health MDGs]
Bollywood divas Alia, Priyanka and Freida bat for Girl Rising
Aug 31, 2015 02:45 PM The Girl Rising campaign is partnering with non-profits working on behalf of girls across India and around the world.
Bihar PHED launches cell for monitoring grievances
Aug 28, 2015 01:20 PM
The PHED-CGRC is also developing a mobile application for the officers to view the complaint.
[Health] [Water and sanitation] [India] [PHED] [SWASTH Bihar] [South Asia] [Bihar]
Indian government launches mobile app on HIV/AIDS
Aug 19, 2015 08:07 PM
This mobile application will provide complete information on HIV and help the government in reaching out to the unreached.
[HIV/AIDS] [South Asia] [Health sector] [Health MDGs] [India HIV infections] [AIDS]
LGBTs should not feel caged in our society, says Priya Dutt
Aug 20, 2015 01:00 AM
Expressing solidarity with gay rights activists, Congress leader Priya Dutt said that sexuality of an individual is a private matter.
[South Asia] [Lesbians] [Transgenders] [Sexual Violence] [India] [Gays]
Bihar village gears up to own water treatment plant
Aug 13, 2015 02:55 PM
In its bid to fight water contamination at the local level, Khaira village in Bihar is set to launch a community owned water treatment plant.
[Sustainable Development] [SWASTH Bihar] [Rural India] [BTAST] [Rural communities] [Water sanitation] [South Asia]

subset: commoncrawl


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Photography:Geneve Hoffman Photography
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Inspired by the story of this historical home, Geneve Hoffman Photography, Beautiful Days and their whole talented team put together a batch of beauty. A story told three ways, all of which spectacular. From the romantic tale of the lovebirdsRead More On SMP


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Sep 25
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The Blood Of Isis , Control The Devastator, Acrucé Mortem , I, The Supplier , Greevace and Alaric's Wrath
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Sounds Like: Black Sabbath, Motörhead, Iron Maiden, Metallica, VENOM
Label: Flying V Radio
Manager: Andy Cauble
Bio: Two brothers, two pairs of ex-bandmates, and what started as a fun project, the trio known as GREEVACE takes its name from its correctly spelled namesake: "Grievous: causing or characterized by severe pain, suffering, or sorrow." A certain General from a very popular Space Movie may have been ...See Full Bio
Greevus, Solo, The Fett
"Greevace – who take their name from a deliberate misspelling of 'grievous' – are a southern US trio, comprising of brothers Andy and Chris Cauble on guitars and bass/vocals respectively and drummer Thomas Whitley, who until coming together in this amalgam at the end of 2008 had spent most of the preceding few years criss-crossing the North Carolina / Georgia border playing in various bands, including a few in which they had teamed up in various guises… Five years into their career, this second self-financed EP is a prime example of decent, hard-working southern metal in the format we know it today, mixing doom, sludge and blues in a way which has been popularized by the likes of Down, Clutch and many, many others. While adding nothing new to the genre, 'Pulling Wool' is an efficient offering: the songs are well-constructed (as is the EP as whole, building from the thoughtful opening of 'Harbinger' to the swelling midsection through to the atmospheric closing instr"


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Indie, garage rock in the vein of Neil Young and Crazy Horse. Loose, ragged, from the heart.
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Looking for a taste of authentic Italian fare without the price of a plane ticket? Then choosing this delightfully warming deal from Sofia's Italian Restaurant and get your fill:
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Sceptre 19-inch LED HDTV has integrated DVD player
If you need a new HDTV for a smaller room with little space, you might want to consider the new 19-inch offering from Sceptre. The new TV is called the E195BD-SHD+ and it weighs in at under 7.3 pounds on the stand. The TV is interesting because it has an integrated DVD player on the side so you don't need another component in the room to watch movies.


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News & Features
This Vintage Eminem Interview From '99 Is Amazing
Busy week, huh? Lets recap. We were served beef, beef, and a side of Future. Sure I've cracked a few jokes here and there, but for the... Read More
Posted 2 months ago by Lucas G.
Eminem's Letter to Tupac's Mother is All the Inspiration You'll Need Today
It's always great to hear of artists paying their respect to other artists, especially when the artists in question happen to be two of their... Read More
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Eminem's Lyric Breakdowns Are Incredible, Check the Rap (Genius) God
Next to Wikipedia, Pornhub, Japanesebugfights.com and of course DJBooth, there is no better site on the whole internwebs than RapGenius.com.... Read More
Posted 6 months ago by Lucas G.
One Song to Prove Eminem Is a Dope Rapper
Water is wet, Rick Ross has man boobs and Eminem can rap. Facts only. Really doe, is there a person on this earth who thinks Eminem isn't a... Read More
Posted 10 months ago by Lucas G.
Obsessively Breaking Down the Demo Version of Eminem's "Lose Yourself"
Unless you were born into the lineage of a Rothschild or Kardashian, there's a part of you that relates to grinding toward a goal, defying the... Read More
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Shady XV: Eminem is Dropping a New Album & I Don't Care
I met Eminem during his hiatus from music, after Encore but before Relapse. Not in the physical, but through a song called, "Sing For A... Read More
Posted 11 months ago by Yoh
Heat Check: How Do You Feel About Eminem's "Guts Over Fear"
YouTube ads are the worst. I mean, I know a quick five second video is a small price to pay to watch a video for a rap song and, of course,... Read More
Posted one year ago by Lucas G.
Heat Check: How Do You Feel About Busta & Eminem's "Calm Down"?
What's better than a new Busta Rhymes song? A new Busta Rhymes song that features Eminem! What's better than a new Busta Rhymes song that features... Read More
Posted one year ago by Lucas G.
Story Behind Eminen's "Monster" More Proof Music Industry is Balls Crazy
I've gone over this before, most deeply with Dr. Dre producer Dawuan Parker, but the biggest lesson I've learned as I've moved beyond this... Read More
Posted one year ago by Nathan S.
The Best & Worst Rap Lines From Eminem's "MMLP2" Album
Since it dropped last week, at least as far as the interwebs are concerned, I've been listening to Eminem's "MMLP2" album and trying to figure... Read More
Posted one year ago by Nathan S.


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Airstream RV Reviews
Perhaps no company is more synonymous with recreational vehicles than Airstream. The Jackson Center, Ohio manufacturer has been building trailers since the 1920s. Airstream trailers are easily recognized for their rounded aluminum bodies. Airstream produces a variety of sizes and styles of travel trailers with a laundry list of amenities.
Recent Airstream RV Reviews
2016 Airstream International Serenity 30 ReviewAirstream's International Serenity travel trailer is designed to help you unwind after an adventurous day.
2015 Airstream Interstate Lounge EXT Wardrobe ReviewAirstream's 2015 Interstate Lounge EXT is perhaps the most versatile RV on the market. This Class B motorhome sleeps up to eight people and features a large galley area, open floor space, and easy-to-access storage.
2015 Airstream Land Yacht 28FB ReviewAirstreams collaboration with Riva boat designer, Mauro Micheli, produced what some are calling the sexiest RV on the market the Land Yacht. Airstream calls it the most luxurious Airstream ever conceived.
More Airstream RV Reviews
2014 Airstream Eddie Bauer Extended 27FB EB Review A sleek and stylish travel trailer 2014 Airstream Classic Limited 31 Review A refined silver bullet 2014 Airstream International Sterling 27FB Review Examining the silver bullet 2013 Airstream Sport 22FB Review Lightweight travel trailer makes hitting the road easy 2012 Airstream Flying Cloud 30 Review This aerodynamic silver bullet is your home on the road 2011 Airstream Avenue 20 Review Cruise the open roads in this unique Class B motorhome 2010 Airstream Sport 22FB Review Compact trailer allows you to just hitch up and go 2010 Airstream Interstate 3500 Review An innovative and versatile coach 2010 Airstream Flying Cloud 30 Review Flying Cloud goes to new lengths 2005 Airstream Safari Review The only trailer fit for a Porsche 2004 Airstream Land Yacht Review A different kind of Class A
View All Airstream News Airstream RV News
Live Riveted: Airstreams New Marketing and Social Media CampaignLive Riveted: Airstream's New Marketing and Social Media CampaignAirstream has announced a new social-media driven campaign it's calling "Live Riveted". The campaign will be anchored by a new microsite ? http://www.liveriveted.com. According to Airstream, Live Riveted is a platform that encompasses the excitement the brand was founded upon and the overriding theme that connects people from all walks of life to Airstream and...
Airstream Land Yacht Concept UnveiledAirstream Land Yacht Concept UnveiledAirstream has unveiled photos and information of its new Land Yacht concept, which is a product of a collaboatino between Airstream, cabinetry maker Tecnoform S.p.A. and the design studio Officinia Italiana Design. "The resulting interior is truly yacht-like and incorporates elements from the world?s finest luxury watercraft," Airstream says in a release. The Airstream Land...
2011 Eddie Bauer Airstream Unveiled2011 Eddie Bauer Airstream UnveiledWith more than 160 years of combined experience, Airstream and Eddie Bauer have partnered to create what Airstream is calling the ultimate adventure travel trailer, which was specifically designed to bring outdoor enthusiasts closer to Mother Nature in comfort and style. The Eddie Bauer Airstream includes a unique sport hatch in the rear of the...
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Another day, another mic session from K-Dot. During
Tag: toca tuesdays
Last Tuesday, Krondon and Phil Da Agony visited DJ Tony Touch's weekly show and put in more than enough work on the microphone.
During DJ Tony Touch's absence, Duck Down took over the show last Tuesday with host Dru Ha and DJ Evil Dee on the 1s and 2s. Before the end of the show, Sean and Fashawn both crack the mic. Listen.
The artist formerly known as Chip Tha Ripper swung by DJ Tony Touch's show a few Tuesdays ago and let it rip. It didn't stink though.
Last Tuesday, Mikey visited DJ Tony Touch's show to promote his free album, Lap Of Lux and spit a few lyrics over the Shade 45 airwaves. Peep his new video here. allindstrom
Like each and every Tuesday, Tony Touch put his guest on the hot seat. Here's what Lupe came up with off the top during last week's episode.
360 appeared last Tuesday on Tony Toca's show on Shade 45. Before the close of his interview, he recited a pair of rhymes over Nas' "Memory Lane" and "Can't Forget About You". Based off his previous material, 60 should've gone harder.


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Dr. Michael N. Desvigne graduated from the Uniformed Services University of the Health Sciences Hebert School of Medicine in 1989. He works in Sun City West, AZ and 1 other location and specializes in Plastic Surgery. Dr. Desvigne is affiliated with Banner Boswell Medical Center and Banner Del E Webb Medical Center.
Plastic Surgery
Medical School: Uniformed Services University of the Health Sciences Hebert School of Medicine; Graduated 1989
*This physician has multiple office locations. See Office Information for details.
15405 N 99th Ave Ste B
Sun City, AZ 85351
18275 N 59th Ave Bldg L
Glendale, AZ 85308
10290 N 92nd St Ste 207
Scottsdale, AZ 85258
20100 N 51st Ave Ste E570
Glendale, AZ 85308
5620 W Thunderbird Rd Ste E2
Glendale, AZ 85306


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We don't know what happened after Matt Santos was elected, because the series ended. Elizabeth Warren would have to start ad libbing shortly after taking office but I find the similarities interesting and something about repeating television plots instead of history seems so very, very American.
Read Whole Story
I always thought that when the United States elected its first female president that it would be a nail biter -- a down-to-the-wire race that would keep us up late on election night before it was official. But Hillary Clinton's presidency is shaping up to be a coronation.
Get top stories and blog posts emailed to me each day..


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Whether white or black, living or dead, down home country or upscale urban, Gabriel's characters are quirky, poignant, and deep. They include: A Gullah woman using folk magic to cast her latest spell. A girl coming-of-age dealing with death in 1940s Tennessee. A wealthy Savannah matriarch with gastrointestinal issues guarding family secrets.
"A treat!"
Annie can hardly believe it: The police say her husband, Max, sits behind bars. They speak of him with a beautiful blonde. By the time Annie bails Max out, the blonde has disappeared and Max is the prime suspect in a crime. The baffling, bloodstained trail leads to the home of the Tarrants, a venerable Southern family with a violent history dating back to the Revolution - and ghosts of a more recent vintage. Infighting and mayhem reign in the family, and a killer wants hide the secrets that haunt the Tarrants.
"Great Plot!"


text: My boyfriend and I stayed over the weekend in this hotel and were very happy with the experience. It is a very nice looking hotel. The hotel staff were all very friendly and helpful, especially Adrian the bartender. The hotel room was clean and comfortable. The fitness facility was spacious and had all kinds of equipment. For the cost it was a very good bargain. We would definitely stay again.


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Trade and Development News
Mexico Ascendant: How to Grow Cross-Border Trade
Aug 05, 2014
Mexico Ascendant: How to Grow Cross-Border Trade, is one of several conferences in The Economist's "Trade Horizons" series and will examine how US companies can best leverage the $507 billion import-export market with Mexico.
Chile busca inversiones chinas en sectores de energía e infraestrucuturas
Aug 01, 2014
Global Fellow Jorge Heine provides insight on potential Chinese investments in Chile in energy and infrastructure sectors.
Jorge Heine: "The relationship with China has to move to the next stage, one that includes energy and infrastructure"
Jul 18, 2014
Program Fellow Jorge Heine is interviewed in Pulso on Chile-China relations on the wake of his departure to Beijing.
Eric Olson Testified Before the US Senate Committee on Homeland Security & Governmental Affairs
Jul 15, 2014
Eric L. Olson, Associate Director of the Latin American Program, joined a panel of experts in testifying before the U.S. Senate Committee on Homeland Security & Governmental Affairs on examining and addressing the root causes behind the rise in apprehensions at the southern border
Latin American Program in the News: Free-market solution to America's immigration dilemma
Jul 05, 2014
Program Director Cynthia J. Arnson is quoted in this article about the United State's role in rebuilding El Salvador.
Latin American Program in the News: Marketplace Morning Report
Jul 01, 2014
Program Director Cynthia J. Arnson comments on Panama's strong economy for the July 1 Marketplace Morning Report.
The North American Development Bank: After 20 Years, Time to Expand
May 22, 2014
After twenty years of success, why wouldn't we want the Bank to do more? Christoper Wilson reflects on the past and future of the NADBank and BECC and how an expanded role could increase exports, create jobs, and spur regional competition.
Don't Pivot Away from TPP
May 21, 2014
As hopes for the United States to sign on to the biggest global trade deal to date rapidly deteriorate, the cost of U.S. political deadlock may be felt most painfully in Asia in the near term, writes Shihoko Goto.
Latin American Program in the News: "A Lasting Friendship with Uruguay"
May 12, 2014
In this op-ed, Latin American Program Director Cynthia J. Arnson outlines the reasons why the meeting today between US President Barack Obama and Uruguayan President Jose Mujica matters for the US.
The Foreign Policy Essay: Could Energy Sanctions on Russia Work?
May 05, 2014
Former Fellow Jeff Colgan who has written extensively on energy issues, offers his thoughts on why sanctions on Russia are not likely to work in checking Russian intervention.


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A question of faith — obligations of good faith in English law
English courts have historically been reluctant to recognise an implied duty of good faith in commercial agreements. However, three recent decisions have cast that understanding into some doubt. The High Court decision in Yam Seng PTE Ltd v International Trade Corporation Ltd [2013] EWHC 111 (QB) found that an enforceable, implied obligation on the parties to act in good faith existed. The decision should be contrasted carefully with Compass Group UK and Ireland Ltd (as Medirest) v Mid Essex Hospital Services NHS Trust [2013] EWCA Civ 200, in which the duty of good faith was limited to the express terms of the contract and indicated that the presence of the implied duty depends on the contractual context. A further comparison can be made with the decision in TSG Building Services Plc v South Anglia Housing Ltd [2013] EWHC 1151, which found that any good faith obligation that does exist will not apply to a clause that provides a right to terminate without cause.
In 2009, Singapore-based company Yam Seng entered into an exclusive distribution deal with International Trade Corporation (ITC) to market Manchester United-branded deodorants and toiletries across various Asian regions.
ITC later breached the contract by: failing to ship orders promptly; failing to make orders available as promised (or, in the case of certain products, at all); undercutting Yam Seng's agreed prices with outlets; attempting to claw back certain distribution rights; and providing false information before and after entering into the contract…
Click on the link below to read the rest of the Addleshaw Goddard briefing.
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The Wizard From Ordinaryville YKTTW Discussion
|The Wizard From Ordinaryville
A schmo from Ordinaryville is The Ace in fantasyland.Description Needs Help Better Name Up For Grabs
"I don't mean to rain on your parade, but we both know that an expert is someone from off-planet with a briefcase." -- Colonel BattleaxeMeet Mike Johnson. He's an ordinary kid from an ordinary town with a paper route and trouble talking to the girl he likes. He has a dog and a bedroom and a haircut. He seems destined to grow up, go to refrigerator repair school, get married, and never leave the humble town of Everyburg. Then Mike gets magically whisked off to Magical Land! He meets elves and fights ogres. He has no frickin' clue how magic works and the social rules and local government are a complete mystery, but thanks to his ability ride a bike and an understanding of how a ground rule double works, he can solve every single problem that has plagued these unwashed heathens for the last five thousand years and rule over them like unto a god. He is... The Wizard From Ordinaryville. The original Trope Namer was The Wizard of Oz. A travelling carny from Omaha with a penchant for fake magic gets whisked away in his hot air balloon to a land of real magic and ends up ruling there as an unquestioned tyrant, the Great and Powerful Oz. Unlike a Normal Fish in a Tiny Pond, where the protagonist possesses a power that makes him unique in Magical Land, The Wizard didn't stand out in Ordinaryville and stands out even less in Fantasyland. Compare to Summon Everyman Hero, where it's explicitly stated that The Everyman is exactly what Magical Land needs, and Down the Rabbit Hole. May have Unfortunate Implications of the Mighty Whitey type.
Examples: Comics
- Adam Strange of DC Comics. Here, he's just a scientist. On Rann, he's the greatest superhero on the planet.
- The Wizard of Oz
- Josh Kirby Time Warrior. The title character is just an ordinary kid (or so he thinks) until he gets caught up in a journey to save time from some evil maniac in a robotic suit. He saves the day numerous times, despite having virtually no experience wielding a sword, not being particularly intelligent, powerful, or skilled. Subverted later, since it turns out he has time manipulation powers.
- In Mom and Dad Save the World, the title characters prove to be this because the invading aliens' hat is Too Stupid To Live.
- Ash from Army Of Darkness was a department store clerk in our era, yet took this trope Up to Eleven after his encounters with the supernatural and unintended trip though time.
- The Wizard of Oz: See above. The titular character was considered as the Trope Namer, but the trope was ultimately given a generic name.
- A Connecticut Yankee in King Arthur's Court: A nineteenth-century man with an inexplicably encyclopedic knowledge of all technology takes advantage of Clarke's Third Law to remake 6th century England as a modern paradise.
- In the Wiz Biz series, "Wiz" Zumwalt is an ordinary computer programmer, who becomes the mightiest wizard in Fantasyland by analyzing the magic.
- In The Chronicles of Narnia, the Pevensee children become kings and queens because of pre-existing prophesy.
- The protagonist of the Cross-Time Engineer novels is another example in the Connecticut Yankee vein.
- In the Spellsinger series, Jon-Tom's knowledge of such Real World trivia as aerobics, socialist political science, and TV commercials wind up saving the party just as often as his emerging magical talent.
- Simon Hawke's Reluctant Sorcerer trilogy deconstructs the "inexplicably knowing things" part by having the "ordinary man" be a genius Absent-Minded Professor and Omnidisciplinary Scientist.
- A very-nearly real life version in The West Wing, when a reporter ends up worshiped as a god by a tribe of cannibals because of his palm pilot's ability to predict the next day's weather.
- The concept album Eldorado by Electric Light Orchestra follows a man on a mission to escape the real world and take up permanent residence in his dream world so he can be this.
- In The Simpsons episode "Lisa The Drama Queen", Lisa and her friend create a fantasy land where they're the rulers.
- Ned Frischman was Dave the Barbarian, who is able to dominate the past with video games and a joke book from 1940.
Replies: 35


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Rate Dr. Jason Profetto
Dr. Jason Profetto's Ratings
This office has very nice people working there and I find it quite easy to make an appointment. Practical for our family to have all of the staff available to help.
Was this rating useful? 0 [[ userState['ratings'][2896073].votes_count ]]
Nice man that really runs an excellent practice. I am happy to be a part of the practice. Chris at front is very nice.
Was this rating useful? 0 [[ userState['ratings'][2894972].votes_count ]]
Impressive staff, willing to accommodate you all the time. Dr. Profetto is also quite amazing, professional, kind, humble, thorough and knowledgeable. Can't beat this office and it's staff. Keep up the good work.
Was this rating useful? 0 [[ userState['ratings'][2888055].votes_count ]]
This guy is a saint. I loved my old doctor but it would take atleast 3 weeks to see him, I can pretty much get an appointment ASAP with Jay. He is also very thorough, my doctor wouldn't go over things and rush me out, this guy will explain everything to you in lay-man's terms. I've never met such a nice doctor before. Recommend to all
Was this rating useful? 0 [[ userState['ratings'][2820988].votes_count ]]
As many before me, I was a patient of Dr. Robinson's who we thought was terrific. We really liked Dr. Profetto when he took over the practice. Have had some major medical issues in the past two years and have only praise for the care received. He definitely includes you in the decision making process about your health. He addresses your concerns without making you feel He advocates for his patients and when a specialist is required he sends you to the best! The staff are knowledgeable and friendly, often going that extra mile.
Was this rating useful? 0 [[ userState['ratings'][2642629].votes_count ]]
I have been with Dr. Profetto since early 2014. My wife and I find Dr. Profetto very informative and explains everything to us. His staff is very nice and always willing to hel when they can. I love the fact that he is accessible by e-mail all the time to prevent wasteful trips to the walk-in clinic.
Was this rating useful? 0 [[ userState['ratings'][2613946].votes_count ]]
I have been with Dr.Profetto since he took over for Dr.Robisnon (which were big shoes to fill) Dr.Profetto's staff are amazing I have never had a problem getting thru, getting same day appointment when needed. Christine who has been responsible for making my specialist appointment has follow up with me on a weekly basic even to say we have not forgot and are working on it. Always greeted by first name and with a smile, I don't think I have ever waited more than 10mins to see Dr.P. I have recently had some health problems and was getting the run around at emergency rooms and dismissed very quickly and told to go home. As extremely frustrating as I found this I truly believe that Dr.Profetto was just as frustrated. There is something to be said about a doctor that advocates on your behalf to emergency room doctors and then personally calls you to tell you what he has set up, which is exactly what Dr.Profetto did! FYI Dr.Profetto was right about my health issues I trust him with my son and myself health and well being 100%. Anyone should consider themselves fortunate to have Dr.profetto as their family doctor!
Was this rating useful? 0 [[ userState['ratings'][2569248].votes_count ]]
I really appreciate his down to earth manner. He knows his stuff and doesn't beat around the bush. Not preachy. Very direct which I really appreciate. Very good care of my son who had testicular cancer... He got the system hopping to make sure he was looked after fast.
Was this rating useful? 0 [[ userState['ratings'][2518374].votes_count ]]
Dr profetto is one of those young, fresh out of school doctors who is very cocky. He has never diagnosed me correctly and when given medication will tell me there are little to no side effects , meanwhile when I go home I google the medication and find a huge list of side effects that he has failed to mention. Not impressed with him as a doctor. Will be happy when I find a new one !!
Was this rating useful? 0 [[ userState['ratings'][2492715].votes_count ]]
Been going to Dr. P since Dr. R. left. Loved Dr. Robinson. He was kind, patient and friendly but his staff were the total opposite. Dr. Profetto made some changes in staff and there is an improvement but they are still somewhat rude and not very friendly. Also, good luck getting through to the office to make or cancel and appointment. They like to take the phone off the hook a lot, then complain when you weren't able to cancel your appointment. They also like for you to do their job for them. Dr. Profetto is very knowledgeable and patient as well.....appears to be caring. Sharp dresser and nice shoes. Decor is very nice but it's more like walking on a red carpet then going to your doctors office. Don't get too big Dr. Profetto!
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Below is a list of all parts for the models starting with 500. To find the repair part you need, you can browse the list below or you can narrow your choices by searching for a part by name or description.
Sold individually.
This ceramic microwave fuse is white in the center, while each end is made of metal. This is a twenty amp fuse.
Part may differ in appearance, but functions same as original.
Note: The beige piece pictured has been redesigned. It no longer has the four corner holes. It now only has 2 corner holes at a diagonal.
This adhesive is made specifically to attach dishwasher tine tips and door gaskets (when necessary).
All brand logos are trademarks of their respective owners.
The PartSelect logo is a Registered Trademark of Atlantic Laundry Centres, Ltd.
Copyright © 1999-2015 , Eldis Group Partnership. All rights reserved.


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"Art making is a form of alchemy, in a way, because you are trying…to make gold from nothing. When it works very well is when you manage to turn the ordinary into the extraordinary."
"For 7 World Trade" (2006)
"I was invited to make something for the lobby at 7 World Trade Center. After much stewing, I came up with the idea of doing text in the wall—not memorial text, but text about the joy of being in New York City. I despaired of writing for the piece, as I often do, and I came to poems by a number of different authors- everyone from Walt Whitman to William Carlos Williams, Elizabeth Bishop, and many more."
- Jenny Holzer


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Toshiba Ultrabook Laptop Heading to Best Buy for $899
Toshiba's Ultrabook joins the Acer Aspire S3 in being the most affordable of Intel's new category of thin-and-light laptops.
Buy an HP Laptop at Wal-Mart, Get a TouchPad for $149
The deal is even sweeter for developers, who can snag two 32GB TouchPads for $150 each without have to buy a PC too.
Laptop Stolen from Checked Bag, Recovered on Craigslist
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One Laptop Per Child Plans to Throw Tablets Out of Helicopters
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Speech Recognition Through the Decades: How We Ended Up With Siri
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"Like" the Acer Aspire S3 Ultrabook? If So, You Could Win One on Facebook
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Prices Going Up on Laptops and Hard Drives, Thanks to Flooding in Thailand
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text: 000 NOUS43 KILX 121326 PNSILX ILZ027>031-036>038-041-141330- PUBLIC INFORMATION STATEMENT NATIONAL WEATHER SERVICE LINCOLN IL 826 AM CDT SAT SEP 12 2015 ...Degraded Signal Persists on Peoria NOAA Weather Radio... The audio for NOAA Weather Radio station WXJ-71 in Peoria, broadcasting at a frequency of 162.475 MHz, has significant distortions due to a damaged phone line that services the transmitter. A persistent loud hum is being produced by the damaged line, which sometimes drowns out the broadcast. According to the phone company, repairs for this issue will not be completed until Monday. Some listeners of WXJ-71 may be able to hear neighboring NOAA Weather Radio stations during this outage: * KZZ-66 in Galesburg (162.400 MHz) * WXJ-92 in Macomb (162.500 MHz) * WXL-22 in Princeton (162.425 MHz) * WXK-24 in Odell (162.450 MHz) * WXJ-75 in Springfield (162.400 MHz) * KZZ-65 in Bloomington (162.525 MHz) $$ Geelhart


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Martin County's comprehensive plan could be decided Tuesday
MARTIN COUNTY — Coming up at Tuesday's county commission meeting is the final decision on proposed changes to three chapters in the Martin County comprehensive plan.
The changes come to commissioners after the efforts of local activist Maggy Hurchalla to restore the comp plan to the one she'd helped construct during her time as county commissioner.
"We got here because the plan you have now is not the award-winning plan," Hurchalla said in March during a Local Planning Agency meeting.
According to the comprehensive plan's text, it was created to protect natural and man-made resources and maintain, through orderly growth and development, the character, stability and quality of life for present and future Martin County residents.
The changes, which take up more than 800 pages in Tuesday's agenda packet, are proposed in chapter 1, the preamble; chapter 2, definitions; and chapter 4, future land use elements.
Many of the concerns with the comp plan changes are centered around Hurchalla's extensive involvement with the process, as well as some of the stricter limits that could befall developers.
"My biggest concern is with this process," said Robert Raynes, a local attorney representing several developers in the county, at the March Local Planning Agency meeting. "This is one person's perspective on how it should be."
Staff is recommending the final decision be held until Aug. 13, so they can address some of the concerns brought up by the state on the comp plan. However, if commissioners decide to adopt the changes at Tuesday's commission meeting and no petitions are filed against the plan, it will become effective 30 days after the decision is made.
The public hearing on the comp plan amendments is set for 2 p.m.
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ADA Turns 25: Reflecting on How the Americans with Disabilities Act Protects the PD Community
Parkinson's may limit some physical abilities, but it should never take away a person's right to live well. Thanks to the Americans with Disabilities Act (ADA), it is much less likely to do so. As we mark the 25th birthday of the ADA — which was signed into law by President George H.W. Bush, on July 26, 1990 — we revisit why it is important for the PD community, including how it can protect you and your family and how to contact PDF for help if it doesn't. The ADA is a civil rights law that prohibits discrimination based on… Read More


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American Audio MX-1400-DSP Review
The American Audio MX-1400-DSP Four Channel 14-inch Professional Mixer for the DJ who needs a lot of features for a decent price…
Staff Review
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Written by djblaze
Posted 8 years ago
Features & Specs
• 4-channel, 14-inch professional mixer
• 3 Phono, 4 Lines, 4 Aux, 3 Mics
• FX with Digital Signal Processing (DSP): Echo, Auto Pan, Flanger, Manual Filter, Auto Filter, Reverb, Trans & Pitch Shifter
• Assign FX to any Mic or channel input
• Parameter Time & Depth adjustment
• Master & Cue BPM analyzer
• Master & Mic trim output adjustment on rear
• Balanced XLR outputs . Booth output (XLR)
• Crossfader assign on each channel
• Crossfader curve
• Auxiliary RCA input on face of mixer
• Stream Flow™ LED indicators
• Superior mic circuitry + long lasting faders
• Q-Start . Recessed back panel
• Digital output (S/PDIF) . Multi-voltage switch
• Dimensions (LxWxH): 14" x 12.5" x 3.25"
• Weight: 15 lbs.
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Microsoft's Patterns & Practices Library is a terrific way of adding some great functionality to your applications. The three aspects of it's EnterpriseLibrary are:
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These tools get added to your project via NuGet.
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- Des Lacs Ferrari
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- Dodge Ferrari
- Donnybrook Ferrari
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I called Nerds On Call to repair some basic problems I was having with my computer. They sent an on-site "technician" to "fix" the problems and downloaded all sorts of their software on my machine.
The computer's performance actually got worse! They sold me on a service where technicican's can site your computer to repair it. After 8 hours, they left my machine with the inability to watch any videos (you tube, etc.)
I finally had to take the machine to another shop and have everything they did un-done and spent $ for that. Don't use them! It's a rip off!